Interrater reliability of the Hamilton Rating Scale for Depression

Personality traits as predictors of exercise treatment adherence in major depressive disorder: lessons from a randomised clinical trial

OBJECTIVE

The objective of this study was to explore the determinants of adherence in the EFFORT-D (EFFect Of Running Therapy) study in a specialised mental health care hospital setting.

METHODS

Patients with major depressive disorder (MDD) were given treatment as usual and half were randomised to an exercise intervention. Adherence was measured at 3 months (T3) and 6 months (T6) and was defined as participation in the overall study protocol (total n = 42, adhered n = 28) or intervention (total n = 24, adhered n = 9). Potential determinants were age, BMI, tobacco and alcohol use, severity of depression, anxiety, fitness (VO₂max kg^-1 and Wmax kg^-1) and personality traits at baseline. ANOVA, Chi-square tests and block-wise logistic regression were performed, and reliability of the scales was determined.

RESULTS

Numbers were found too low for analyses on smoking, drinking and anxiety. Higher agreeableness was significantly associated with better adherence to the overall study protocol (OR 1.2; p = 0.03; 95% CI: 1.01-1.4) and severity of depression was negatively associated with adherence in the intervention group (OR 0.70; p = 0.046;95% CI: 0.49-0.99).

CONCLUSIONS

To adhere to a study protocol involving exercise or to a clinical exercise programme, MDD patients need substantial personal support. Measurement of personality traits and the severity of depression as potential predictors of adherence could be considered for this purpose. Keypoints Adherence to exercise and study protocols in a randomised controlled trial was low Patients with severe major depressive disorder need substantial personal support Measurement of personality traits could be considered.

EFFORT-D: results of a randomised controlled trial testing the EFFect of running therapy on depression

Results of a randomised controlled trial testing the EFFect Of Running Therapy on Depression.

BACKGROUND

This randomised controlled trial explored the anti-depressive and health effects of add-on exercise (running therapy or Nordic walking) in patients with Major Depressive Disorder (MDD).

METHODS

Patients were recruited at three specialised mental health care institutions. In the intervention group exercise was planned two times a week during 6 months, the control group received care as usual. Observer-blinded measurements included Hamilton-17 depression scores and several health and fitness parameters. Submaximal bicycle-tests were performed at inclusion, 3, 6 and 12 months. The effects of exercise were assessed by effect size, intention-to-treat and analysis per protocol using General Linear Models (GLM) with time x group interactions.

RESULTS

In total, 183 patients were assessed for eligibility and 135 were excluded (40% of the potential participants declined to participate mainly due to a lack of time and motivation). Together with a drop-out of 55% at 6 months, this reduced the power of the study severely. As a result, statistical analysis was performed only on the first 3 months of the study. Data were ultimately analysed from 46 patients, of which 24 were in the intervention group. Significantly more women were in the intervention group, and depression and fitness were higher in the control group. Participants showed 2-3 points less depression on average after 3 months. However, the GLM showed no effect on depression (Cohen's d < 0.2, F = .13, p = .73) in both the intention-to-treat and per protocol analyses. However, large effect sizes (Cohen's d > 0.8) were found for aerobic capacity (VO2max∙.kg- 1, F = 7.1, p = .02*), maximal external output (Wmax∙.kg- 1, F = 6.1, p = .03*), and Body Mass Index (F = 5, p = .04*), in favour of the intervention group.

CONCLUSIONS

In this selective and relative small clinical population with MDD, an anti-depressive effect of the exercise intervention could not be measured and is also unlikely due to the very low effect size. An integrated lifestyle intervention will probably be more effective than a single add-on exercise intervention. However, significantly increased fitness levels may contribute to the alleviation of current cardio-metabolic risk factors or prevention of these in the future.

TRIAL REGISTRATION

Netherlands Trial Register (NTR): NTR1894 on July 2nd 2009.

Combination treatment for acute depression is superior only when psychotherapy is added to medication

BACKGROUND

Although several forms of effective therapy exist for outpatients suffering from major depressive disorder, many patients do not profit from treatment. Combining psychotherapy and medication may be an effective strategy. However, earlier studies have rarely found a clear advantage for the combination. Where an advantage was found, a possible placebo effect of adding 2 types of treatment could not be ruled out as cause for the superior effect of the combination.

METHODS

A total of 353 patients were screened, of whom 193 were randomized over 4 conditions: nefazodone plus clinical management, interpersonal psychotherapy (IPT), the combination of the two or the combination of IPT and pill-placebo. All patients suffered from major depressive disorder and had a score of at least 14 on the 17-item Hamilton Rating Scale (HAMD). The patients were treated for 12-16 weeks. At baseline, at 6 weeks and on completion of treatment, ratings were performed by independent raters. The primary outcome measure was the HAMD, and the Montgomery-Asberg Depression Rating Scale (MADRS) the secondary outcome measure.

RESULTS

Of the 193 patients included, 138 completed the trial. All treatments were effective. Using a random regression model, no differences between treatments were found on the HAMD. On the MADRS, however, the combination of medication with psychotherapy was more effective in reducing depressive symptoms compared to medication alone, but not to psychotherapy alone or IPT with pill-placebo.

CONCLUSIONS

The results of this study yield support for the use of combining medication with psychotherapy instead of using medication only in the treatment of depressed outpatients. Combination treatment does not have an advantage over psychotherapy alone in the present study.

A comparison of the 'Hamilton Rating Scale for Depression' and the 'Montgomery-Asberg Depression rating Scale'

Although the Hamilton Rating Scale for Depression (HRSD) is the most frequently used rating scale for quantifying depressive states, it has been criticized for its reliability and its usability in clinical practice. This criticism is less applying to the Montgomery-Asberg Depression Rating Scale (MADRS). Goal of the present study is to investigate the reliability and validity, and clinical relationship between the HRSD and the MADRS. For 60 out-patients with diagnosed depression (DSM IV296.2x, 296.3x, 300.40 and 311.00), the HRSD and MADRS were scored at baseline and 6 weeks later by an independent rater according to a structured interview. Also the Clinical Global Impression (CGI) was assessed by a psychiatrist. Satisfying agreement was found between the totalscores (r= .75, p>.000 en r=.92, p>.000 respectively, at baseline and 6 weeks later). Furthermore agreement was found between the items of both scales, and these agree with the clinical impression. The reliability of the MADRS is more stable than the reliability of the HRSD (α = .6367 and α =.8900 vs α = .2193 and α = .8362 at baseline and at endpoint respectively). Considering the ease of scoring both scales in one interview and the widely international use of the HRSD, scoring both the HRSD and the MADRS to measure the severity of a depression seems to be an acceptabel covenant.

Brofaromine versus lithium addition to maprotiline. A double-blind study in maprotiline refractory depressed outpatients

Depressed outpatients (n = 51) resistant to treatment with maprotiline were treated in a blind, randomized, single-centre study, for 6 weeks with either the reversible and selective monoamine oxidase A-inhibitor (MAO-A-I), brofaromine or lithium addition to maprotiline. The Hamilton Rating Scale for Depression was scored by an independent rater before and after the 6 week treatment period. No significant differences in efficacy were found between the two treatment regimes. In the patients who completed the trial, brofaromine was well tolerated with the exception of insomnia. Anticholinergic effects as well as thyroid dysfunctions (17 out of 20) were more frequent in the maprotiline/lithium group.